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Employment Application
Step 1 of 2
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APPLICANT INFORMATION
Legal Name
*
First
Middle
Last
Present Address
*
Street Address
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
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Montana
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New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Home Phone
*
Cell Phone
Email Address
Are you applying for a driver position?
*
Yes
No
Position applied for
*
Current employee referral?
*
Yes
No
If so, name of that employee:
*
Special training or skills (languages, machine operations, etc.) that would benefit you in the job for which you are applying:
Would you accept full-time work?
*
Yes
No
Would you accept part-time work?
*
Yes
No
On what date, would you be available for work?
*
Date Format: MM slash DD slash YYYY
Have you ever been employed here?
*
Yes
No
If yes, dates:
Are you legally eligible for employment in the United States? (If yes, proof is required if hired.)
*
Yes
No
If you are under 18 years old, can you provide a work permit if required?
Yes
No
EDUCATION BACKGROUND
High School:
Location
Course of study
Did you graduate?
Yes
No
Degree or diploma
College:
Location
Course of study
Did you graduate?
Yes
No
Degree or diploma
Graduate School:
Location
Course of study
Did you graduate?
Yes
No
Degree or diploma
Vocational Training/Other:
Location
Course of study
Did you graduate?
Yes
No
Degree or diploma
Continuing Education:
EMPLOYMENT EXPERIENCE
List your most recent employer first.
Employer
Contact Name
May we contact?
Yes
No
Address
Phone
Job Title
Hourly rate/salary
Date employed from (mm/dd/yyyy):
Date Format: MM slash DD slash YYYY
Date employed to (mm/dd/yyyy):
Date Format: MM slash DD slash YYYY
Were you subject to the Federal Motor Carrier Safety Regulations (FMCSRs) while employed by the previous employer?
Yes
No
Was the previous job position designated as a safety sensitive function in any DOT regulated mode, subject to alcohol and controlled substances testing requirements as required by 49 CFR Part 40?
Yes
No
Employer
Contact Name
May we contact?
Yes
No
Address
Phone
Job Title
Hourly rate/salary:
Date employed from (mm/dd/yyyy):
Date Format: MM slash DD slash YYYY
Date employed to (mm/dd/yyyy):
Date Format: MM slash DD slash YYYY
Were you subject to the Federal Motor Carrier Safety Regulations (FMCSRs) while employed by the previous employer?
Yes
No
Was the previous job position designated as a safety sensitive function in any DOT regulated mode, subject to alcohol and controlled substances testing requirements as required by 49 CFR Part 40?
Yes
No
Employer
Contact Name
May we contact?
Yes
No
Address
Phone
Job Title
Hourly rate/salary:
Date employed from (mm/dd/yyyy):
Date Format: MM slash DD slash YYYY
Date employed to (mm/dd/yyyy):
Date Format: MM slash DD slash YYYY
Were you subject to the Federal Motor Carrier Safety Regulations (FMCSRs) while employed by the previous employer?
Yes
No
Was the previous job position designated as a safety sensitive function in any DOT regulated mode, subject to alcohol and controlled substances testing requirements as required by 49 CFR Part 40?
Yes
No
Employer
Contact Name
May we contact?
Yes
No
Address
Phone
Job Title
Hourly rate/salary:
Date employed from (mm/dd/yyyy):
Date Format: MM slash DD slash YYYY
Date employed to (mm/dd/yyyy):
Date Format: MM slash DD slash YYYY
Were you subject to the Federal Motor Carrier Safety Regulations (FMCSRs) while employed by the previous employer?
Yes
No
Was the previous job position designated as a safety sensitive function in any DOT regulated mode, subject to alcohol and controlled substances testing requirements as required by 49 CFR Part 40?
Yes
No
I certify that all the information submitted by me on this application is true and complete, and I understand that if any false or misleading information, omissions or misrepresentations are discovered, my application may be rejected, and if I am employed, my employment may be terminated at any time.
If hired, I agree to conform to the company’s rules and regulations, and I understand that these rules and/or employee handbook do not form a contract of employment either expressed or implied, and I agree that my employment and compensation can be terminated, with or without cause and with or without notice, at any time, at either my or the company’s option.
I also understand and agree that the terms and conditions of my employment may be changed, with or without cause and with or without notice, at any time by the company. I understand that no company representative, other than its president, and then only when in writing and signed by the president, has any authority to enter into any agreement for employment for any specific period of time, or to make any agreement contrary to the forgoing.
I expressly authorize, without reservation, the employer, its representative, employees or agents to contact and obtain information from all references (personal and professional), employers, public agencies, licensing authorities and educational institutions and to otherwise verify the accuracy of all information provided by me in this application, resume or job interview.
I hereby waive any and all rights and claims I may have regarding the employer, its agents, employees or representative, for seeking, gathering and using truthful and non-defamatory information, in a lawful manner, in the employment process and all other persons, corporations or organizations for furnishing such information about me.
I understand that this application remains current for only 30 days. At the conclusion of that time, if I have not heard from the employer and still wish to be considered for employment, it will be necessary for me to reapply and fill out a new application.
Agreement
*
I agree
Applicant's Signature
*
Date
*
Date Format: MM slash DD slash YYYY
Farm Service Coop
2303 Pine Street
Harlan, IA 51537
712-755-3185
MVR Release Authorization
Personal and Employment Background Check
Date
*
Date Format: MM slash DD slash YYYY
Branch Office
Legal Name
*
First
Middle
Last
Address
*
Street Address
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Social Security Number
*
Driver License Number
CDL?
*
Yes
No
CDL Type
*
Exp. Date
*
Date Format: MM slash DD slash YYYY
State
Hazmat / Tank
Yes
No
Other Endorsements
Date of Birth
*
MM
DD
YYYY
Phone Number
*
Cell Number
Current DOT Physical
Yes
No
Expiration Date
Date Format: MM slash DD slash YYYY
My Driving Record along with my personal and employment background may be obtained as part of the Farm Service Cooperative’s evaluation of my job application/employment. The reports may be procured by Farm Service Cooperative, and may include my driving record and an assessment of my insurability under the Company’s insurance coverage’s. By signing this disclosure, I hereby authorize the Company to procure such reports about me from time to time, as it deems appropriate, to evaluate my insurability or for other permissible purposes.
Authorization
*
I agree
Electronic Signature of Job Applicant/Employee
*
DRIVER APPLICATION
Legal Name
*
First
Middle
Last
Maiden Name, If Any
Address
*
Street Address
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
DRIVING EXPERIENCE
STRAIGHT TRUCK
Type (Van, Tank, Flat, etc.)
Date From
Date Format: MM slash DD slash YYYY
Date To
Date Format: MM slash DD slash YYYY
Approx. No. Miles (total)
TRACTOR AND SEMI TRAILER
Type (Van, Tank, Flat, etc.)
Date From
Date Format: MM slash DD slash YYYY
Date To
Date Format: MM slash DD slash YYYY
Approx. No. Miles (total)
TRACTOR - TWO TRAILERS
Type (Van, Tank, Flat, etc.)
Date From
Date Format: MM slash DD slash YYYY
Date To
Date Format: MM slash DD slash YYYY
Approx. No. Miles (total)
OTHER
Type (Van, Tank, Flat, etc.)
Date From
Date Format: MM slash DD slash YYYY
Date To
Date Format: MM slash DD slash YYYY
Approx. No. Miles (total)
ACCIDENT RECORD FOR THE PAST 3 YEARS
Dates
Nature of Accident
No. Fatalities
No. Injuries
Chemical Spills? Y/N
TRAFFIC CONVICTIONS AND FORFEITURES FOR THE PAST 3 YEARS OR MORE
Date Convicted
Violation
State of Violation
Penalty (forfeited bond, collateral and/or points)
Have you ever been denied a license, permit or privilege to operate a motor vehicle?
*
Yes
No
If yes, explain
*
Has any license, permit or privilege ever been suspended or revoked?
*
Yes
No
If yes, explain
*
TO BE READ AND SIGNED BY APPLICANT
I authorize you to make sure investigations and inquiries to my personal, employment, financial or medical history and other related matters as may be necessary in arriving at an employment decision. (Generally, inquiries regarding medical history will be made only if and after a conditional offer of employment has been extended.) I hereby release employers, schools, health care providers and other persons from all liability in responding to inquiries and releasing information in connection with my application.
In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge. I understand, also, that I am required to abide by all rules and regulations of the Company.
"I understand that information I provide regarding current and/or previous employers may be used, and those employer(s) will be contacted, for the purpose of investigating my safety performance and history as required by 49 CFR 391.23(d) and (e).
I understand that I have the right to:
Review information provided by my current/previous employers;
Have errors in the information corrected by previous employers and for those previous employers to re-send the corrected information to the prospective employer; and
Have a rebuttal statement attached to the alleged erroneous information, if the previous employer(s) and I cannot agree on the accuracy of the information.
Date
*
Date Format: MM slash DD slash YYYY
Electronic Signature
*
Enter your full name
This certifies that I completed the application, and that all entries on it and information in it are true and complete to the best of my knowledge.
Date
*
Date Format: MM slash DD slash YYYY
Electronic Signature
*
Enter your full name
Note: A motor carrier may require an applicant to provide information in addition to the information required by the Federal Motor Carrier Safety Regulations.
Email
This field is for validation purposes and should be left unchanged.
Reach Farm Service Cooperative
📞
Tel:
1-712-755-3185
✉
Email:
info@fscoop.com
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Address:
PO Box 429, 2308 Pine Street, Harlan, Iowa 51537
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